How To Use CPT Code 49084

CPT 49084 describes the procedure of peritoneal lavage, which involves washing out the peritoneal cavity to detect internal bleeding. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49084?

CPT 49084 can be used to describe the procedure of peritoneal lavage, which is performed to detect the presence of internal bleeding. This code is used when a healthcare provider washes out the peritoneal cavity using either saline or warm water, and may rely on imaging guidance to view internal structures.

2. Official Description

The official description of CPT code 49084 is: ‘Peritoneal lavage, including imaging guidance, when performed.’

3. Procedure

1. During the procedure, the healthcare provider inserts a long, flexible plastic tube into the abdomen through a small incision near the belly button.
2. A catheter is then inserted towards the pelvis through the incision.
3. The provider administers either saline or warm water and washes out the peritoneal cavity.
4. Imaging guidance may be used to view internal structures.
5. The provider checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

Peritoneal lavage is performed on patients who require the detection of internal bleeding. This procedure is typically done when other diagnostic methods are inconclusive or unavailable. It is important to note that CPT code 49084 should not be reported in conjunction with codes 76942, 77002, 77012, or 77021. For percutaneous image-guided drainage of retroperitoneal abscess by catheter, use code 49406.

5. When to use CPT code 49084

CPT code 49084 should be used when a healthcare provider performs peritoneal lavage, including imaging guidance, to detect internal bleeding. It is important to ensure that the procedure is necessary and meets the qualifying circumstances mentioned above.

6. Documentation requirements

To support a claim for CPT 49084, the healthcare provider must document the following information:

• Reason for performing peritoneal lavage and the need for imaging guidance
• Details of the procedure, including the use of saline or warm water
• Date and duration of the procedure
• Any findings or observations during the procedure
• Any additional procedures performed or instruments used
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 49084, ensure that the procedure includes peritoneal lavage and imaging guidance. Do not report CPT code 49084 in conjunction with codes 76942, 77002, 77012, or 77021. It is important to follow the specific guidelines provided by the payer and use appropriate modifiers if necessary.

8. Historical information

CPT 49084 was added to the Current Procedural Terminology system on January 1, 2012. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs peritoneal lavage with imaging guidance to detect internal bleeding in a trauma patient.
2. During a surgical procedure, a provider performs peritoneal lavage to assess for any signs of bleeding or infection.
3. A patient presents with abdominal pain, and a healthcare provider performs peritoneal lavage to rule out internal bleeding as the cause.
4. Following a car accident, a patient undergoes peritoneal lavage to detect any internal injuries or bleeding.
5. A healthcare provider performs peritoneal lavage during a diagnostic procedure to assess the extent of a patient’s abdominal injury.
6. During an emergency surgery, a provider performs peritoneal lavage to identify any sources of bleeding or infection.
7. A patient with a history of abdominal trauma undergoes peritoneal lavage to monitor for any signs of internal bleeding.
8. As part of a diagnostic workup, a healthcare provider performs peritoneal lavage to evaluate a patient’s abdominal pain.
9. A patient with a suspected abdominal injury undergoes peritoneal lavage to determine the presence of internal bleeding.
10. During a laparoscopic procedure, a provider performs peritoneal lavage to assess for any signs of infection or bleeding.